Millions of Americans receive post-acute care after a hospital visit, provided by nursing homes, inpatient rehabilitation facilities, long-term care hospitals, home health agencies, and hospices. The Ways and Means Health Subcommittee held a hearing examining the current state of Medicare beneficiary access to critical post-acute care services and the stability of providers delivering such care. The hearing also explored innovative ways to enhance access and promote care coordination, like leveraging telehealth and remote patient monitoring and continuing to align payment systems.
Borrowing from the Private Sector: Implementing Pay for Performance
Patients need better health outcomes and taxpayers deserve to see their dollars go towards higher quality care that actually leads to healthier patients. A witness suggested tying Medicare reimbursement to the quality of care provided. This idea, already widespread in the private sector, would incentivize hospitals and other health providers to improve performance.
Rep. Vern Buchanan (FL-16): “You touched on performance to pay. I know being in business 30 years before I got up here, that was a big premise of mine, is trying to make sure we tied the behavior to what we were trying to incentivize people. Can you explain what you mean by that?”
Jonathan Fleece, Florida home-based care provider: “If you look at the current star rating system that is prevalent in Medicare today, it is one that does not adequately pay for performance for the providers…We would certainly advocate that for those organizations that have higher star ratings, that they get paid more under the reimbursement system. That would be one model of a pay for performance. We also stand proudly behind taking risk, through our PACE programs, programs for all-inclusive care for the elderly, where we are ultimately caring for those that would otherwise be in a nursing home, and receive both the Medicaid and the Medicare component for our PACE programs. We become responsible for that performance. We become responsible for making sure that they have the right care, right place, right time.”
Unified Post-Acute Payment System Could Allow for Innovative Care Models
A glaring problem repeatedly brought up by witnesses is that payment systems and regulations for the post-acute care settings are fragmented and misaligned, even though Medicare spends $60 billion on post-acute care annually. This undermines the promise of the important care these providers furnish – such as the lower rates of mortality and hospital readmissions associated with skilled nursing facilities and improvements in everyday activities like bathing and dressing that are associated with home health. A unified Medicare payment system for post-acute services could simplify patient access to care and cut red tape for providers all while delivering more taxpayer value.
Rep. Adrian Smith (NE-03): “Ms. Grabert, you mentioned the impact a unified post-acute payment system could have on the post-acute landscape. How would such a system make it easier to provide a skilled nursing facility at-home option for our seniors?”
Lisa Grabert, health care policy expert: “I do think that what you’ve described is a perfect model that fits under the umbrella of regulatory relief that can be done in tandem with the post-acute care unified PAC PPS. It’s a model that would thrive under such a system.”
Long-Term Care Hospitals Are Critical Tools in Providing Post-Acute Care
Long-term care hospitals (LTCHs) care for some of the sickest Medicare patients needing the most specialized care. Witnesses detailed how recent changes to LTCH admission criteria and payments for high-cost patients could hurt the ability of these hospitals to treat these critical patients and remain financially solvent. Ways and Means Committee Members including Reps. Carol Miller (WV-01), Kevin Hern (OK-01), and Lloyd Smucker (PA-11) have authored legislation to correct the unintended consequences of these changes and ensure patients have access to care at LTCHs.
Rep. Carol Miller (WV-01): “Long-term care hospitals are critical for patients who require extended care. The cost to treat the complex medical needs that the LTCH patients require can be significant. The reimbursement system for the LTCHs is structured to help manage these costs, but recent changes to the high-cost outlier threshold have introduced new financial challenges… This puts additional strain on providers, and it affects the level of care available to patients. I introduced the Patient Access to Long-Term Care Hospitals Act, which will provide adequate reimbursements for LTCHs… With this in mind, Mr. Dongilli, what has been the impact of the increase in the high-cost outlier threshold for LTCHs on providers, such as yourself, and the patients you treat?”
Paul Dongilli, Nebraska hospital leader: “From a provider and patient perspective…when [the high-cost outlier threshold was lower], we were able to allow more patients who would enter into the facility who we knew would become high-cost outliers, because that fixed loss amount was such that we could manage that and still make a relatively small margin within our long-term care hospital. At that time, it was close to 4 percent. When [the threshold] doubled, what we saw was that we had to provide more scrutiny even though we continued to admit those patients who would go into high-cost outlier status. The financial impact of doubling it resulted in our overall LTCH margin following from that four percent to a minus three percent. When you’re talking about a significant number of cases, and for us at that time, our high-cost outlier threshold was about 30 percent. Now, we have to limit that in order to maintain financial solvency, which denies patients’ access to the care that they need at that point in time.”
Telehealth Could Be Solution for Nationwide Staffing Shortages
Across the country, staffing shortages in the post-acute care field have harmed patient access to health care. These shortages will be exacerbated by misguided government policies like the Biden Administration’s nursing home staffing mandate, which could result in as many as 290,000 residents being forced from their nursing homes. Rep. Brian Fitzpatrick (PA-01) and a witness from Texas both shared the scale of staffing shortages in their areas. Telehealth could be a solution for these staffing shortages and allow health care professionals to check on more patients than otherwise would be possible.
Rep. Brian Fitzpatrick (PA-01): “A key challenge facing my constituents back home in Bucks and Montgomery counties in Pennsylvania, has been the increasing staff shortages in the health care industry, forcing many patients to be turned away for necessary care, or alternatively, to receive suboptimal care to meet their needs. This is coupled with increased pressure on the professionals administering this very care. As has been brought up in this hearing, staffing for these specialized post-acute care facilities is especially concerning. In my home state, Pennsylvania is projected to have the most dire shortage of staff for skilled nursing facilities by 2026. Reportedly, nearly half of Pennsylvania Healthcare Association members plan to close or sell at least one of their SNFs [skilled nursing facility] this year. Dr Madison, in your professional experiences in home health, can you speak to how staffing has changed in recent years, and moreover, how these potential challenges impacted your ability to treat your patients?”
Dana Madison, Texas home health administrator: “In Lubbock, Texas, six years ago, we did a study, and at that point, we were a city of 260,000. We were 1,000 RNs [registered nurses] short and 1,000 LVNs [licensed vocational nurse] short, and that’s a hole that you can never back fill enough. We are dealing with it right now. Telehealth would help with that tremendously. If we could do telehealth visits, one particular nurse could make 20 visits a day instead of the normal eight that they make. For those patients that don’t need to be actually have hands on care that day, I think telehealth would be a great way to take care of those patients.”